What follows are items I found interesting in magazines I’ve recently read. Normally I would have tweeted these links, but since I was on vacation from Twitter (see My Twitter vacation), I decided to create a type of blog post called Reading Notes (see Blogging and my Twitter vacation).
The bulleted titles below link to the specific item. There’s more detail on the articles I mention under References. OA indicates open access. $ indicates a pay wall. Note that emphasis in quotations has been added by me. Read more
The final post in this series on interrogating inequality is about another possible clue as to why we no longer seem to care about inequality. It’s from the book Excellent Sheep by William Deresiewicz.
The role of elite institutions of higher education
In his book, Deresiewicz argues that elite educational institutions reproduce a class system, exacerbate inequality, retard social mobility, and perpetuate privilege. Not only is the elite class that’s created by these institutions “isolated from the society that it’s supposed to lead.” It runs society for its own exclusive benefit. (emphasis added)
Our educational system, it’s been suggested, is what America developed in lieu of a European-style social welfare state to mitigate inequality. Instead of “handouts,” opportunity. And once upon a time, it worked as advertised. Both the unprecedented expansion of public higher education and the equally unprecedented opening of access to the private sort were instrumental in creating a mass middle class, and a new upper and upper middle class, in the decades after World War II. But now instead of fighting inequality, the system has been captured by it.
I mention this not simply as another possible clue, but because the article (Rebooting Social Science) that prompted me to write this series of posts appeared in Harvard Magazine. That may or may not be relevant to the attitude it expresses towards inequality, an attitude I found troubling. Read more
Continuing my discussion of interrogating inequality, here is another post with a possible clue as to how we came not to care. This one considers a rather wide expanse of history
We have neglected to cultivate a culture that cares
I recently struggled through the book Governmentality: Power and Rule in Modern Society by Mitchell M. Dean. The book is very clearly written — the publisher calls it “exceptionally clear and lucid,” and it is. The book is intended, however, for experts already familiar with Foucault’s writings and lectures, particularly those on governmentality.
I frequently found myself in a fog, but I persisted. I was hoping to find ideas that would explain the changes that produced the contemporary self, including why we have become a society that fails to care about increasing inequality. And I did find a brief reference to this development in a section where Dean asks: “Where do our notions of ‘care’ come from?” Why do we think the state should care for the welfare of its citizens? Read more
How did we become a society that passively accepts the injustice and discrimination inherent in inequality? How did we come not to care? It would undoubtedly take me a very long time to adequately address that question, but in this and the next two posts I offer a few small clues.
We are each the stars of our own lives
First up is Pierre Rosanvallon’s recent book The Society of Equals. In a review of the book, Paul Starr mentions what may be an impediment to a society of equals: We see ourselves not simply as individuals, but as unique singularities. (emphasis added in this and the following quotations)
The story that Rosanvallon tells here is that as new forms of knowledge and economic relations have emerged, people have come to think of their situation in less collective ways. Since the 1980s, he writes, capitalism has put “a new emphasis on the creative abilities of individuals,” and jobs increasingly demand that workers invest their personalities in their work. No longer assured of being able to stay at one company, employees have to develop their distinctive qualities—their “brand”—so as to be able to move nimbly from one position to another.
As a result of both cognitive and social change, “everyone implicitly claims the right to be considered a star, an expert, or an artist, that is, to see his or her ideas and judgments taken into account and recognized as valuable.” The demand to be treated as singular does not come just from celebrities. On Facebook and many other online sites millions are saying: here are my opinions, my music, my photos. The yearning for distinction has become democratized.
Rosanvallon does not criticize the society of singularities, with its “right to be considered a star.” Since it’s now a fact of life, we need to figure out how to deal with it. Read more
In a previous post (Interrogating inequality: An annoying article) I discussed an article about a group of interdisciplinary scholars who were “interrogating” the societal consequences of increasing inequality. While the group included individuals with backgrounds in psychology and history, it was dominated by academic scholars who specialized in economics, business, and public policy. (The first three individuals quoted in the article are a professor of business administration, a professor of management practice, and a senior lecturer at Harvard Business School.)
The concluding comments on inequality were offered by a professor of social policy. This particular individual “recently revealed” that he had given up on his long-term research on the social effects of inequality (a project he’d started in the 1960s) because there were no “convincing conclusions.” In other words, research had not been able to provide statistical proof that inequality is in any way harmful to society as a whole. As one of the social scientists put it: (emphasis in original)
The problem is, there is no consensus in the research on the consequences of inequality.
May I suggest that a more significant problem is that social scientists ask the wrong question. As Tony Judt writes (emphasis added): Read more
The previous post, this post, and the next four were provoked by an article that made two assertions I found troubling: one, that there is no consensus among researchers on the consequences of inequality, and two, that evidence of a “causal relationship” between income inequality and health is unclear. In the last post, I discussed those assertions and quoted Daniel Goldberg on whether health behaviors determine health. To continue …
Ground control, we have causation
Over the past few months, since I first read that annoying article, I keep coming across accounts that offer evidence of the harms that result from inequality (particularly in childhood), as well as actions that doctors and politicians are willing to take to address the problem. We’ve known for some time that there was a correlation between poverty and health. Now we’re finally discovering the mechanisms, the causation. Read more
I recently read an article that really annoyed me. It was called “Rebooting Social Science: The interdisciplinary Tobin Project addresses real-world problems.” I began to realize that I wouldn’t see eye to eye with this article when I got to the section that discussed the “real-world problem” of inequality. The section was titled “Interrogating Inequality.” Not “addressing” inequality. Interrogating. Shades of “doubt is our product,” as I’ll explain.
One of the scholars interviewed for this article characterized inequality as “the most contested of contemporary issues.” The evidence cited for said contestation was the lack of agreement on whether inequality contributed to the recent financial crisis. Some claim that it did. Others, however,
dismiss this argument, viewing rising inequality “as little more than a hiccup” or even celebrating it as “a favorable development … in the progress of American capitalism.”
As it turns out, the real issue being “contested” by these “social scientists” (economists, not sociologists) is not whether inequality exists or whether it’s just a hiccup or an inevitability of capitalism. No. (emphasis in the original)
The problem is, there is no consensus in the research on the consequences of inequality.
No consequences? What about childhood trauma, increased rates of disease, shorter lifespans, human dignity? Well, it turns out those things may affect individuals, but what these researchers are looking for are societal consequences. For example, is there a relationship between inequality and economic growth? Evidently, if we cannot detect a decrease in economic growth, there’s no reason to alleviate inequality. And it seems social scientists disagree among themselves about the quality of the evidence on that issue. Read more
The August issue of The Journal of Medicine and Philosophy does not have a specific theme. The nine articles address a number of quite interesting issues, among them:
How existential psychotherapy can offer powerful insights to patients recovering from severe mental disorders such as psychosis
How a preference in athletics for natural talent over artificial enhancements (such as doping) may reflect “unsavory beliefs about ‘nature’s aristocracy’ ”
How rich, educated, white males may be just as, if not more, vulnerable to threats posed by physician-assisted suicide and voluntary active euthanasia than members of marginalized groups
When the decision is made not to administer artificial hydration and nutrition, can the responsibility for the patient’s death be attributed to the underlying pathology, even when that is not the cause of death
The right to procreate: Is it possible for prospective mothers to wrong prospective fathers by bearing their child
Note that the articles in this journal are not open access and that I have added the emphasis in the following extracts and abstracts. Read more
Jill Lepore has an article in a recent New Yorker called The Disruption Machine: What the gospel of innovation gets wrong. Her target is Clayton M. Christensen’s book The Innovator’s Dilemma and, specifically, disruptive innovation. As usual with Lepore, her essay is personable and well-argued. What I liked most about it, though, was its brief discussion of how unfortunate it is that professions such as higher education and medicine are being privatized (if they’re not already) and administered to maximize efficiency, making profits more important than students or patients. (emphasis added) Read more
Chris Hayes sometimes gets dismissed as just another commentator on a failing liberal TV network, but I found his book Twilight of the Elites a perceptive, well-written account of how American meritocracy perpetuates inequality.
I especially liked this passage from Hayes’ review:
Why, one might ask, in an economy in which 49 million Americans are poor and the median household income hovers around $51,000, should we care about the psychic plight of 23-year-olds making $90,000? Because these are the people who run our country, and the process by which their own empathetic faculties are destroyed is a key part of how this entire corrupt finance-state is maintained.
The Affordable Care Act (ACA, aka Obamacare) will expand insurance coverage to millions of Americans (for example, to individuals with pre-existing conditions). Having insurance, however, does not mean a primary care physician will be willing to take you on as a new patient. There are multiple reasons for this, as discussed in a recent article in JAMA, Implications of new insurance coverage for access to care, cost-sharing, and reimbursement (paywall).
We no longer live in the Marcus Welby days of a medical practice that has only one or two doctors. The “vast majority” of primary care practices, however, have only 11 or fewer physicians (according to JAMA). Many of these practices are already at or near capacity, which means that adding new patients may require additional expenses (staff, office space, equipment). For small practices, the decision to add new patients is first and foremost a business decision: Will the increased income cover my increased expense? Here are some of the things the “vast majority” of providers will be thinking about:
The ACA lowers the cost of health insurance for many individuals, in particular, for people with relatively low incomes. These patients, however, will pay more for health care itself due to higher co-pays (that part of the cost not covered by insurance) and higher deductibles (the maximum annual out-of-pocket expense). In the past, the main burden of collecting fees was on insurance companies. Under the ACA, it may be health care providers who are faced with a “collection burden.”
What is a general health checkup? It’s when you visit a doctor not because of an ongoing chronic condition or because you’re concerned about new, unexplained physical or mental symptoms, but because you want a general evaluation of your health. The assumption behind such a visit is that if you do this regularly, you may prevent a future illness.
A recent issue of JAMA had two articles on general health checkups. One of them asked the question: What are the benefits and harms of general health checks for adult populations? It summarized a 2012 Cochrane review that addresses this question (it was written by three of the four authors of that review). The review concluded that health checkups were not correlated with fewer deaths (reduced mortality), neither deaths from all causes nor from cancer or cardiovascular disease in particular. Health checkups were associated with more diagnoses, more drug treatments, and possible (but probably infrequent) harm from unnecessary testing, treatment, and labeling. Read more
Rick Santorum, responding to Obama’s statement that “the middle class in America has really taken it on the chin,” said that he would never, ever, stoop to using the word “class.” (Dorothy Wickenden in The New Yorker)
Sociologist Annette Lareau has done extensive field work that involves unobtrusively inserting herself (or her field-worker assistants) into the homes and daily lives of families (treat us like “the family dog,” she recommends). Her observations have led her to identify a difference in the parenting styles of families from different social classes. Middle-class families practice what she calls concerted cultivation: parents teach their children skills that prepare them to engage successfully with the social institutions of adult, middle-class life. Working class families value natural growth: parents give their children a great deal of unstructured time in which they must use their own creativity to plan and execute their activities.
Lareau’s work is described in her book Unequal Childhoods: Class, Race, and Family Life. Originally published in 2003, it was updated for a 2011 edition. It’s a wonderful book. I think of it whenever people argue – as they frequently do in the US – that America is the land of equal opportunity, therefore those who fail to exert themselves sufficiently have only themselves to blame.
I’d like to cite two stories from Lareau’s book that relate to health care. Read more
Attending to the social determinants of health is especially important for children, since children’s experiences – of poverty, poor nutrition, trauma, abuse, neglect, the prenatal environment – can affect physical and mental health for an entire lifetime. As the authors of a recent commentary in JAMA write: “Pediatrics … continues to evolve clinical practice aimed at addressing social determinants because of children’s exquisite vulnerability to the deleterious effects of the social and physical environment, especially the aggregation of social factors associated with poverty.”
The occasion for the commentary – titled Addressing the Social Determinants of Health Within the Patient-Centered Medical Home: Lessons From Pediatrics — is the imminent implementation of the Affordable Care Act. The medical home (also known as the patient-centered medical home) is a concept that originated in pediatrics. The basic idea is that when a team of providers — physicians, nurses, nutritionists, pharmacists, social workers – work together, they can best meet the needs of patients. The Affordable Care Act has several provisions designed to establish and promote medical homes, and the authors of this commentary (two pediatricians and a family medicine practitioner) ask: What has pediatrics learned about addressing social determinants that can be translated to medical homes for adults. Read more
This feels encouraging: Two Viewpoint articles in a recent issue of JAMA (The Journal of the American Medical Association) on improving population health (both behind a paywall, unfortunately).
What is population health? Apparently it depends on who you ask. If you ask those with a financial stake in the health care delivery system, population health means improving the health of patients who currently use (i.e., pay for) the system. You get a different answer if you ask those involved in public health, community development, or social services. They believe “population” should include everyone in the entire geographic community, whether or not those individuals are able to use or benefit from health care services. They also believe “health” should include quality of life and economic well-being – measures that prevent disease in the first place – and not just conditions addressed by the medical model of disease.
What I especially liked about Stephen Shortell’s article – Bridging the Divide between Health and Health Care – was its economic realism. I dearly wish that those with a financial interest in the health care industry, as well as politicians who control health policy, would acknowledge that the way to improve health is to address its social determinants. But trying to change the hearts and minds of stakeholders is like pushing against the tide. Read more
Continued from the previous post, where I noted that the Lalonde report — despite its good intentions — was followed by an emphasis on healthy lifestyles and personal responsibility for health, as well as increased health care costs.
Personal responsibility and social class
In Why Are Some People Healthy and Others Not?, Marmor et al, writing in 1994, were disappointed that the Lalonde report had not effectively prompted governments to address the underlying causes of health and disease. One reason for this, they believed, was that health policy reflects public opinion. If the public holds traditional views on what makes us sick (pathogens), what prevents disease (medical care), and what we can do to be healthy (take personal responsibility), new policies that include social determinants are unlikely. Those who are on the forefront of professional, scientific opinion may very well understand the importance of social determinants, but public opinion changes slowly. Without an education program, such as the relatively successful anti-smoking campaign, the public is unlikely to endorse change.
This is certainly true, although I believe there’s also something more fundamental at work here, namely, how a society accounts for the different life outcomes of its citizens. In Unequal Childhoods: Class, Race, and Family Life, Annette Lareau describes the assumptions people make when they hold others personally responsible for their life circumstances. Read more
Continued from the previous post, where I discussed the expansion of universal health care prior to the 1970s, how this created a growing demand for health care, and the problem health care costs posed for governments, especially when the economy suffered a downturn in the seventies. One response to the situation was to consider new ideas. Rather than limit strategies to what could be done by the health care industry, why not directly address the underlying causes of disease by considering social determinants of health.
[the] first modern government document in the Western world to acknowledge that our emphasis upon a biomedical health care system is wrong, and that we need to look beyond the traditional health care (sick care) system if we wish to improve the health of the public.
The US Congress emulated this thinking in 1976 by creating the Office of Prevention and Health Promotion. The US Department of Health, Education, and Welfare began publishing the document Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention in 1979. The response in European countries — caught in the same bind of greater demand, increasing costs, and the financial consequences of a deteriorating economic landscape – was similar.
The common thread in these new perspectives on health was the assertion that health could be improved — without increasing health care costs — if we concentrated on such things as the work environment (occupational health), the physical environment (air and water pollution, pesticides and other carcinogens in food), genetics, and healthy lifestyles. The approach was broad: the environment was considered at least as important as the promotion of healthy lifestyles. Read more
In the 1970s, public health policies began to promote the idea that individuals are responsible for their health and therefore have an obligation to adopt healthy lifestyles. Over the ensuing decades, health became both an extremely popular topic for media coverage and a lucrative market for vendors of health-related products and services. What followed was a substantial increase in health consciousness and greater anxiety about all things that concern the body.
Do healthy lifestyles actually produce better health? That they should may seem like common sense, which is one reason it’s been so easy to promote the idea that they do. The question is difficult to answer with absolute certainty, however. For one thing, the behavior that counts towards a healthy lifestyle does not readily lend itself to the objective measurements required for reliable scientific evidence. Defining health is also tricky. Lifespan is often used to compare the ‘health’ of different nations, but this fails to capture the subjective sense of health that is meaningful to individuals. Perhaps most important, while in theory a healthy lifestyle might improve health, that does little good if – as is now obvious – it’s extremely difficult to maintain behaviors that require things like changing what we eat and how often we exercise.
A related question would be: Did the promotion of healthy lifestyles reduce health care costs? This too seems like a sensible assumption, and the assertion is quite popular, especially among politicians. Health care costs have increased to hand-wringing levels. Promoting healthy lifestyles costs governments next to nothing, while the cost of health care is all too easily quantified. Read more
Why is it so hard to convince policy makers worldwide to address the social determinants of health, including poverty, hunger, and income inequality? Judging by the excerpt below, we shouldn’t count on the US to champion this cause any time soon. It’s from a document called “The Future We Want,” issued by the Rio+20 conference last June. The US requested changes to the document, indicated in bold (additions) and strike-outs (deletions).
Eradicating poverty is the greatest global challenge facing the world today and an indispensable requirement for sustainable development. In this regard we are committed to free humanity from extreme poverty and hunger as a matter of urgency.
We recognize that promoting universal access to social services can make an important contribution to consolidating and achieving development gains.
We strongly encourage initiatives at all levels aimed at providingenhancing social protection for all people. Read more
A year ago, when I decided to call my declining rate of blogging a ‘sabbatical,’ I wrote down some questions to explore while I took time off to read.
How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?
At the time I thought I would read primarily in the history of medicine, and that was how I started. Appreciating the historical context of medicine is important for understanding both how medicine ended up where it is today and what medicine could become. “The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time,” I wrote.
Now that I’ve become more familiar with the social determinants of health, I’m less optimistic about the future. The problem is not simply that the corporatization of health care has increased dissatisfaction among both doctors and patients. The problem is that our focus is so narrowly limited to health care systems that we fail to see the larger issue. As one metaphor puts it, doctors are so busy pulling diseased patients out of the river, there’s no time to look upstream and ask who’s throwing the bodies into the water. Read more
Continued from parts one and two, where I defined the terms used in the following diagram of my blogging interests. Click on the graphic for a larger image.
If I had written the previous two posts a year ago, I would have realized how much my interests were intertwined. I guess I wasn’t ready to do that. Anyway, in this post I catalog some of the connections.
~ Healthism and psychological and physical conformity: Healthy lifestyle campaigns promote an ideal way of life that encourages individuals to alter their behavior and appearance. Although it’s true that we would all be better off if we didn’t smoke, that doesn’t make anti-smoking laws any less authoritarian, i.e., requiring conformity (see the section on anti-authority healthism in this post). The fitness aspect of healthy lifestyles promotes the desirability for both men and women of acquiring (i.e., conforming to) specific body images.
“Self-help is the psychiatric equivalent of healthism.” That’s a slogan I made up. I’m not sure yet if it will stand up to scrutiny. Certainly the self-help industry encourages self-criticism, which leads to a preoccupation with those aspects of personality currently considered undesirable. Read more
Continued from part one, where I discussed the first three of my six interests: healthism, medicalization, and psychological and physical conformity. Click on the graphic below to see a larger image.
The social determinants of health
Social determinants of health (often abbreviated SDOH) refers to unequally distributed social and economic conditions that correlate with unequal and inequitable distributions of health and disease. Presumably there is a causal relationship between the two, not merely a correlation. Definitively identifying the causal mechanisms, however, is difficult. A great many things influence our health (including things we’re not even aware of yet), and it can be difficult to isolate and scientifically study some of the ones we strongly suspect, like poverty, isolation, or a sense of being socially inferior.
The medical model is the preferred framework in modern westernized societies for explaining the distribution of health and disease. It emphasizes risk behavior (smoking, diet), clinical risk factors (blood pressure, blood sugar, cholesterol levels), genetics, health care access and quality, behavioral change, and patient education. One common characteristic of the medical model’s explanation of health and disease is that causes are located in the individual (behavior, genes), not in the individual’s economic and social environment. Read more
It’s always hard to be sure about these things, but I think the reason I decided to take a ‘sabbatical’ from blogging last July was that I was interested in too many seemingly unrelated topics. Writing about all of them left me feeling like I never got to the ‘meat’ of any one of them. And I couldn’t convince myself to focus on just one or two things, since that would mean abandoning the others, which I was unwilling to do.
Now that I’ve taken the past year to read and reflect, I find – duh! – that my interests are not as unrelated as I’d assumed. In hindsight, I should have realized this long ago, but, alas, I did not. I’m writing this post to clarify to myself what I now see as the common threads that connect my interests.
Here is a diagram that groups my interests into six categories. (Click on the graphic to see a larger image.)
Four of the six categories relate to all five of the others. The two outliers (neoliberalism and medicalization) are not as directly related as I feel the others are. Read more
Pierre Fraser is an author, essayist, and PhD candidate in sociology at Université Laval. We share an abiding interest in healthism or, as Pierre would say, santéisme. For the original version of this post, see L’individu devenu déchet. Pierre blogs at Pierre Fraser and tweets as @pierre_fraser.
Unlike some countries these days, America seems to have little difficulty tolerating the idea of multiculturalism. An explanation for this, perhaps, can be found in the American ideology of success. This ideology acts like a suction pump, removing any alternative explanations of how the world should work. This myth is contagious. The American dream – you can be whatever you want to be – circles the globe like a very powerful trademark.
In the myth of the self-made man, everything is possible. So powerful is this belief that nothing seems able to deter it. Contact with this idea creates the equivalent of an addiction. Every addiction, however, has its downside. We forget that every day “two types of trucks leave the factory: one type goes to the warehouse and department store, the other to the landfill. We have grown up with a story that considers only the first truck and ignores the second. ”  Read more
I thought I had exhausted my need to read or listen to anything more on the Supreme Court decision on the Affordable Care Act (ACA). I read something today, however, that made me realize I hadn’t been paying close enough attention. It was an article published by The New England Journal of Medicine called The Road Ahead for the Affordable Care Act
The author, John McDonough, points out the significance of the upcoming November elections. In particular, he clarified for me why recent mentions of ‘reconciliation’ are not just referring to how the ACA was passed in 2010.
In January 2013, if Democrats hold the White House and Senate and regain control of the House, the ACA will be implemented mostly as constructed. If Republicans capture the White House and Senate and retain House control, the ACA will face major deconstruction early in 2013. Republican leaders will attempt to use Congress‘s budget-reconciliation authority to enact extensive repeal — and will need only 51 Senate votes, with no filibuster threat. If control of the White House and Congress is divided between the parties, then conflict over the law will persist. Thus, the November elections increasingly feel like a referendum on the ACA.
Our financially and professionally entrenched system of medical care has a vested interest in maintaining an understanding of health that preserves the status quo. Part of the power of our biomedical culture is that its contingency – the very real possibility that it could be different — is ordinarily invisible to us. What would it take to imagine a widely shared understanding of health that called for dramatic changes not only in how our health care needs are met, but in the conditions under which we live our lives? This is the question that I hope an examination of healthism will provoke. Read more
Throughout history there’s been an understandable desire to find connections between our behavior and our health. Human beings have practiced health regimens involving diet, exercise and hygiene since antiquity. When medicine was based on the humoral theory of disease, for example, individuals were advised to purge the body in the spring and, in the summer, avoid foods or activities that caused heat. Bathing in ice water was recommended in the 19th century. Mark Twain quoted the advice: “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.” Read more
My real objection to medicine as a science is that by focusing on what can readily be quantified, it ignores what cannot, such as the social determinants of health and disease. Medicine’s desire for the respectability that comes with being a science gets in the way of determining what could actually make us healthier. Read more
Will the London riots raise questions about a world that doesn’t care about the socially disadvantaged? Questions, yes. But will that be enough to bring about a change in attitudes and policies? Probably not. Unfortunately, the situation will need to get much worse. Even when that happens, current financial interests are likely to prevail. A discouraging prospect, yes, but a struggle worth waging. Read more
Poverty in developed countries may never be overcome, simply because the rich no longer … need the poor to get rich. … The misfortune of being exploited has been succeeded by the still worse misfortune of no longer being exploitable.Read more